Basic Nursing Skills 1 Flashcards

A CNA is performing passive range-of-motion exercises on a resident's shoulder. The resident suddenly reports sharp pain during abduction. What is the MOST appropriate immediate action?

Answer: Stop the movement, support the joint, and report the pain to the nurse

When a resident reports sharp pain during ROM exercises, the CNA must stop immediately to prevent injury, support the joint in a comfortable position, and report to the nurse. Continuing despite pain can cause serious musculoskeletal damage. Documentation follows after stopping and reporting, not before.

While repositioning a completely dependent resident using a draw sheet, the CNA notices the resident's sacral area has a small blister over an area of redness that was not present two hours ago. This finding MOST likely represents which stage of pressure injury?

Answer: Stage II

A Stage II pressure injury is characterized by partial-thickness skin loss presenting as a shallow open ulcer or intact/ruptured blister. The presence of a blister over redness distinguishes it from Stage I (intact skin with non-blanchable redness) and from Stage III or IV (full-thickness tissue loss). It is not unstageable because the wound bed is visible.

A CNA is assisting a resident who uses a cane to ambulate. The resident's left leg is weaker. When descending stairs, which sequence is CORRECT?

Answer: Cane and weak leg together, then strong leg

When descending stairs, the cane and the weak leg move down together first, then the strong leg follows. This ensures the strong leg bears weight while the weak leg is repositioned with cane support. The mnemonic 'up with the good, down with the bad' applies — on ascent the strong leg leads, on descent the weak leg (with cane) leads.

A CNA is measuring urinary output for a resident on intake and output monitoring. The resident voided 180 mL, then the CNA accidentally spills 60 mL while pouring it into the measuring container. How should the CNA document the output?

Answer: Document 180 mL, because the original void volume is known

The resident voided 180 mL — that is the actual urinary output. The spill is a handling error that does not change what the resident produced. The CNA should document 180 mL as the true output and report the spill to the nurse. Documenting 120 mL would falsely indicate decreased urinary output and could affect clinical decisions.

During oral care for an unconscious resident, which positioning and technique combination BEST reduces aspiration risk?

Answer: Lateral (side-lying) with head slightly lower than body; use minimal fluid and suction available

For unconscious residents, lateral positioning with the head slightly dependent allows fluid and secretions to drain out of the mouth rather than toward the airway. Suction should be available to clear secretions. The supine or Fowler's positions increase aspiration risk because fluid can pool at the pharynx. High-Fowler's with head tilted back is contraindicated as it opens the airway directly to fluid.

A CNA notes that a resident's gastrostomy tube (G-tube) feeding bag still has 200 mL remaining, but the pump alarm is sounding. The skin around the insertion site appears red and there is dried formula crust around the tube. Which action falls WITHIN the CNA's scope of practice?

Answer: Clean the skin around the insertion site with soap and water and report site findings to the nurse

CNAs may perform routine skin care around tube insertion sites, such as cleaning with soap and water, and must report abnormal findings like redness to the nurse. Managing the feeding pump alarm, flushing the tube, adjusting flow rates, or repositioning a tube are nursing or specialized tasks that fall outside the CNA scope of practice. The CNA's role is observation, routine hygiene, and communication to the licensed nurse.